What people believe / by Axel Mundigo

What people believe I know nothing about contraceptives and what I do not understand does not interest me. J#Jmen who can have children should have them -for women are for that, for giving birth. A woman living in a city slum Over the past two decades, family planning has been accepted by coun- tries at different levels of develop- ment and of diverse ideological orien- tation as the best policy response available to their governments to deal with rapid population growth. Since the landmark World Population Con- ference at Bucharest in 1974, most developing countries have adopted policies and carried out programmes designed to increase access to and availability of contraceptive methods through national family planning programmes. Worldwide use of contraception, although steadily rising, is still far from universal. The United Nations estimates that contraceptive preval- ence for all developing countries is about 38 per cent as opposed to 68 per cent in industrialised regions. In Africa, where access to services and availability of methods is limited, on- ly 11 per cent of all women of repro- ductive age use contraceptives. Ac- cess is also insufficient in most rural areas of the Third World. WHo's Special Programme of Re- search Development and Research Training in Human Reproduction (HRP) has taken up the challenge of increasing, through a global effort, access to better and more varied choices to regulate fertility in both men and women. Its biomedical re- search focuses on clinical studies to improve old methods of contracep- tion or devise new ones and also find better ways to detect or prevent infer- tility. Its social science research acti- vities are designed to identify those behavioural, social and related fac- tors that impede or facilitate the use of different methods. 8 by Axel Mundigo Culture plays an important role in determining attitudes and setting barriers to the acceptance of modern contraception. The opinions of wo- men interviewed in urban slums ref- lect, in ways that no statistics can transmit, the challenge and the com- plexity of the issue. Health planners often ask: When we place services in communities, why do women still shy away from the use of these methods? Why does a substantial unmet need for contraception persist despite major My opinion is that it is a good thing to use contraceptives because there are women who have children every year and that is an abuse of their bodies. Photo WHO/UNICEF/M. Murray-Lee efforts by governments? Why do surveys show that, although people say they don't want any more child- ren, they don't use contraception? Why are men so opposed to contra- ception? The replies are often puzzling. Here are some real-life examples illustrating these barriers to contra- ceptive use. A recently completed study in Pa- kistan shows a very common finding, especially among rural families, that less than 20 per cent of the families have ever used any method and that although a very high proportion of both men and women did not want an additional child, yet 80 per cent of these very same families said they would not use a method. The reasons for this are many and include prejudices, fear and misinfor- W o RLD HEALTH, November 1987 mation about methods. The com- ment of one woman was : My husband and I wanted only two children, in order to give them a good education. He does not make much mo- ney and we are very poor. We now have four and we don't want any more child- ren. We have to feed, educate and dress them. I know that the clinic offers fam- ily planning services, but neighbours told me it is very dangerous, that if ano- ther baby comes he will be born with de- fects and that it is very bad for the health of the women to take these medicines. Another puzzling aspect in many surveys is that families tend to ex- press a low demand for children, that is, an ideal of two or three children, which is close to what families in ma- ny developed societies wish to have. On the other hand, the supply of children in many communities indi- cates that excess reproduction is sometimes twice the expressed ideal family size. This was another wo- man's point of view: I would like to have only two child- ren because that is a good number; one can give them food and a good educa- tion and, if one is also working, it is ea- sier to deal with fewer children. I have already had ten children but four of them died and I hope that God hears our wishes and does not give us any more children. I feel old and sick and we are very poor. I first thought of having only three children but gradual- ly more came. Then I thought it was good because they would help us in old age. But now, I believe that having so many children is a lot ofwork, no one helps you and the more children you have the more you suffer. The expectation that many child- ren will assist the parents in old age is, under circumstances of extreme poverty, a powerful argument in favour of having a large number of offspring. With modernisation, changes in labour markets and job opportunities come about, and fami- lies see their sons and daughters de- parting for other places. Often the rationale for continuous reproduc- tion turns towards having a younger one at home to look after the pa- rents when all the older children have left. In many cultures, the husband is opposed to using contraceptive me- thods within the family relationship. The wife's continuous pregnancies are a demonstration of the man's masculinity as well as some sort of security. Men often associate contra- WoRLD HEALTH, November 1987 ception with prostitution. Besides the main target of family planning has been the women, and men have, for the most part, felt that this is an area where they have been excluded. One wife said: I would like to have only two child- ren because we can hardly feed them, and if I have more money, I should also eat better. But we are poor and our in- come is insufficient to buy what is need- ed and to educate them well. When I speak with my husband about using a method, he says no, because all I want is to walk the streets. Women in many developing countries may know about intra-uterine devices, but their awareness of how to use them is often superficial. Photo WHO/P. Almasy And the husband: My wife will have all the children that God gives her and only He knows how many will come. I do not want you to speak to her about those things (family planning) because the nurses only put those ideas in the heads of women. Again the wife: If I said to him that I was planning to use something to stop having children he would hit me. Among the barriers to using con- traceptive methods are the precon- ceived ideas that people have of their actual or presumed side-effects. In a small community or neighbourhood, it is sufficient for one woman to expe- rience excessive bleeding for the ru- mour to run around that the method is dangerous. Such unwarranted fears can be illustrated by the following comment: Before you have children you don't think about their number - at least I did not -and now I have already seven. This is a sufficient number for people like us. But the idea of avoiding having children is not a good one because con- traceptives ruin your blood system. In many developing countries there is poor knowledge of available me- thods. They may be able to list the pill, intra-uterine devices and injectables, but their awareness of how to use them and how to act to prevent pregnancy is often superficial. One woman said: I do not want to have any more child- ren and I would like to learn how one can stop having them. A neighbour told me that she knew some roots to make teas that were very effective, and that she could get them for me for very little money. I have also heard of pills and injections that have the same effect but I am not sure how they work. In order to highlight the challenge that health planners, providers and service programmes encounter in overcoming the barriers to greater contraceptive use, we have empha- sised here the difficulties that people face in making the decision to use existing methods. But it would not be fair to end without providing an example of an argument that reflects why women worldwide are increas- ingly using contraceptives: My opinion is that it is a good thing to use contraceptives because there are women who have children every year and that is an abuse of their bodies. Since there are new methods to avoid having children and our situation is everyday more difficult, it is important to stop after three children or at least space them well apart. Motherhood is full of honour but very cruel. The Special Programme of Re- search, Development, and Research Training in Human Reproduction is vigorously pursuing research in deve- loping countries in order to gain a deeper understanding of all these is- sues. While numerous surveys have provided information on reproduc- tive preferences and levels of contra- ceptive use, issues such as the rea- sons for non-use or for ineffective use remain largely unexplained. More needs to be learned about the dynam- ics of contraceptive use, how deci- sions are made, how choice is deter- mined, how women switch from one method to another in the hope it is more suitable to them, and how ser- vices respond to these needs. After all, what determines the continuity of use will be the key to effective long- term protection against pregnancy. These crucial factors must be under- stood if policies and programmes are to have a real impact on world popu- lation growth. • 9